Nasal cavity and paranasal sinuses carcinoma

Sinonasal 1Sept. 2001

Catholic University of Louvain, St - Luc University HospitalHead and Neck Oncology Programme

Nasal cavity and paranasal sinuses carcinoma




•• WorkWork--up procedureup procedure

•• TNM stagingTNM staging

•• Primary treatmentPrimary treatment

•• FollowFollow--upup

•• Treatment of recurrent and/or Treatment of recurrent and/or metastaticmetastatic diseasedisease

•• ReferencesReferences



Clinical evaluation Evidence Option

l complete history of the diseasel professional evaluationl weight and weight lossl performance status (Karnofsky / ECOG-WHO)l evaluation of cranial nerves and audiometryl fiberoptic examination of H&N mucosal neck examinationl drawing of any lesionsl biopsy (using endoscopic endonasal approach)

Type CType CType CType CType CType CType CType CType C

Std.Std.Std.Std.Std.Std.Std.Std.Std.



Advanced clinical evaluation Evidence Option

l Ophthalmologic examinationl Dental examination by oral surgeonl Prosthetic rehabilitation (if maxillectomy)l Neurosurgery examination (depending on surgical

approach)l Plastic surgery examination (depending on surgical

approach)

Type CType CType CType C

Type C

Std.Std.Std.Std.

Std.



Laboratory tests Evidence Option

l hemogram, coagulation tests, liver enzymes, kidney function

l pituitary function: cortisol, TSH, free T4, LH, FSH, GH, free testosterone and testosterone (male only), progesterone and oestradiol (female only), prolactine, IGF-1

l thyroid function: TSH (if radiotherapy scheduled)

Type C

Type C

Type C

Std.

Std.

Std.



Imaging Evidence Option

l Loco-regional: CT scan and MRI1

l Panoramic dental X-rayl Metastatic work-up: chest X-ray, thoracic spiral

CT scanl Additional examination depending on previous

findingsl PET scanl Face / sinus standard X-ray

Type CType CType C

Type C

Type 3Type 3

Std.Std.Std.

Std.

Invest.Indiv.

1See guidelines for loco-regional imaging



Pathologic examination Evidence Option

Standards of the British Royal College ofPathologists (endorsed by EORTC)1

Type C Std.

1See pathology guidelines












Staging Evidence Option

l TNM classification (5th ed., 1997)l WHO International Classification of Diseases for

Oncology (ICD-O 9 or ICD-O 10)l Specific staging for nasal cavity carcinoma and

esthesioneuroblastoma

Type CType C

Type C

Std.Std.

Std.



TNM/AJCC 1997 StagingTNM/AJCC 1997 StagingMaxillary sinus:

• Tx: primary tumor cannot be assessed• T0: no evidence of primary tumor• T1: tumor limited to the antral mucosa with no erosion or destruction of bone• T2: tumor causing bone erosion or destruction, except for the posterior antral wall, including

extension into hard palate and/ormiddle nasal meatus• T3: tumor invades any of the following: bone of posterior wall of maxillary sinus,

subcutaneous tissues, skin of cheek, floor or medial wall of orbit, infratemporal fossa, pterygoid plates, ethmoid sinuses

• T4: tumor invades orbital contents beyond the floor or medial wall including apex and/or any of the following: cribriform plate, base of skull, nasopharynx, sphenoid sinus, frontal sinus

Ethmoid sinus:• Tx: primary tumor cannot be assessed• T0: no evidence of primary tumor• T1: tumor confined to ethmoid with or without bone erosion• T2: tumor extends into nasal cavity• T3: tumor extends to anterior orbit and/or maxillary sinus• T4: tumor with intracranial extension, orbital extension including apex, involving sphenoid

and/or frontal sinus and/or skin of nose



TNM/AJCC 1997 StagingTNM/AJCC 1997 Staging

• N0: no regional node metastasis• Nx: regional nodes cannot be assessed• N1: single ipsilateral node, ≤ 3 cm• N2a: single ipsilateral node, > 3 cm and ≤ 6 cm• N2b: multiple ipsilateral nodes, ≤ 6 cm• N2c: controlateral or bilateral nodes, ≤ 6 cm• N3: node > 6 cm



TNM/AJCC 1997 StagingTNM/AJCC 1997 Staging

•• Mx: DistantMx: Distant metastasis cannot be assessedmetastasis cannot be assessed•• M0: No distantM0: No distant metastasismetastasis•• M1: DistantM1: Distant metastasismetastasis



Specific stagingSpecific staging

Nasal cavity (University of Florida):• Stage I: limited to site of origin• Stage II: extension to adjacent sites(eg orbit, nasopharynx, paranasal sinuses, skin,

pterygomaxillary fossa)• Stage III: base of skull or pterygoid plate destruction; intracranial extension

Esthesioneuroblastoma (Kadish):• Stage A: disease confined to the nasal cavity• Stage B: disease confined to the nasal cavity and one or more paranasal sinuses• Stage C: disease extending beyond the nasal cavity and the paranasal sinuses, including

involvement of the orbit, base of the skull or intracranial cavity, cervical lymph nodes, or distant metastasis












Primary treatment for the neck Evidence Option

l N0: elective treatment (ND or radiotherapy depending on thetreatment of the primary T) of both sides of the neck is indicatedwhen tumor extends to the nasopharynx and/or soft palate

l > N0: appropriate ND on both sides of the neck + postoperativeRxTh1

Type 3

Type 3

Std.

Std

1 see guidelines for post-operative radiotherapy



Primary treatment: surgical procedure of the “T” site: Ethmoïdsinus

Evidence Option

l T1-T2: - surgery: external approach ± post-op RxTh1 endoscopic approach ± post-op RxTh1

l T3: - surgery: external approach ± post-op RxTh1

- Type I-II-IVb: frozen section- Type III-IVa: exenteration- Type ethmoïd roof I: frozen section- Type ethmoïd roof II: craniofacial resection with

or without maxillectomy + post-operative RxThl T4: - surgery using craniofacial resection if tumor does not

extend to: - bilateral apex, bilateral periorbita - cavernous sinus - massive infratemporal fossa

+ post-operative RxTh - definitive RxTh for unresectable tumor for surgical or medical reason

Type 3Type 3Type 3

Type 3

Type 3

Std.Indiv.Std.

Std.

Indiv.




Primary treatment: surgical procedure of the “T” site:Esthesioneuroblostoma

Evidence Option

l T1: - surgery using transfacial approach + post-operative RxTh if positive section(s)

l T2-T4: - surgery using craniofacial resection + post-operative RxTh

Type 3

Type 3

Std.

Std.



Primary treatment: surgical procedure of the “T” site:Maxillary sinus

Evidence Option

l T1-T2: - partial maxillectomy ± post-operative RxTh1

l T3: - total maxillectomy + post-operative RxThl T4: - radical maxillectomy +/- exenteration, +/- cranio-

facial resection + post-operative RxTh - definitive RxTh for unresectable tumor for surgical or medical reasons

Type 3Type 3Type 3

Type 3

Std.Std.Std.

Indiv.




Primary treatment: specific pathology Evidence Option

l Extra-nodal lymphoma: chemotherapy ± RxThl Plasmocytoma: RxThl Rhabdomyosarcoma: induction chemotherapy followed ,

according to tumor response, by RxTh or surgery + post-operative RxTh

Type 3Type 3Type 3

Std.Std.Std.








•• Treatment of recurrent and/orTreatment of recurrent and/or metastaticmetastatic diseasedisease




Follow-up Evidence Option

l Clinical examination-cavity cleaning and general ENT examination

including neck palpation and fiberoptic examination every 2 months (first 2 years), every 6 months (3rd-5th year), then every year (> 5 years)

-dental examination every 6 monthsl Imaging

-loco-regional: CT-scan or MRI after 6 months, then 6-12 months later

-chest X-ray every yearl Laboratory tests

-thyroid function (TSH) every year if radiotherapy delivered on the neck

-pituitary function every year if RxTh delivered on the pituitary gland

l Evaluation of late toxicity (EORTC/RTOG) scale

Type C

Type C

Type C

Type C

Type C

Type C

Type C

Std.

Std.

Std.

Std.

Std.

Std.

Std.












Salvage treatment for recurrent disease: general principle

Treatment will depend on:l Site and extension (rTNM stage)l Previous treatment(s)l Performance statusl Patient wishes



Salvage treatment for recurrent disease Evidence Option

l rT1-rT3 N0-M0-surgery ± RxTh1

-RxTh-chemotherapy

l rT4, any N, M0-chemotherapy-best supportive care

l T0-anyrN-M0-ND-RxTh-chemotherapy

l Metastasis-chemotherapy-best supportive care

Type CType CType C

Type CType C

Type CType CType C

Type CType C

Std.Indiv.Indiv.

Std.Std.

Std.Indiv.Indiv.

Std.Std.

1depending on previous radiotherapy












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ReferencesReferences



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•Margaret S. Brandwein, Adina Rothstein, William Lawson, Carol Bodian, Mark L. Urken Sinonasal melanoma.Arch Otolaryngol Head Neck Surg 123 : 290-296 ; 1997 •Neil Bhattacharyya, Allan F. Thornton, Michael P. Joseph, Max L. Goodman, Philip C. Amrein Successful treatmentof esthesioneuroblastoma and neuroendocrine carcinoma with combined chemotherapy and proton radiation. Arch Otolaryngol Head Neck Surg 123 : 34-40 ; 1997•P. Janecka, Chandranath Sen, Laligam Sekhar, Hugh Crtin Treatment of paranasal sinus cancer with cranial basesurgery : results. Laryngoscope 104 : May 1994•Patricia K. Ha, David W. Eisele, Frank J. Frassica, Marianna L. Zahurak, Edward F. McCarthy Osteosarcoma of thehead and neck : a review of the Johns Hopkins experience. Laryngoscope 109 : 964-969 ; 1999•Paul A. Levine, Richard Gallagher, Robert W. Cantrell Esthesioneuroblastoma : reflections of a 21-year experience. Laryngoscope 109 : 1539-1543 ; 1999•Paul A. Levine, W. Copley McLean, Robert W. Cantrell Esthesioneuroblastoma : the university of Virginiaexperience 1960-1985 Laryngoscope 96 : July 1986•Paul P. Knegt, Kim W. Ah-See, Lilly-Ann vd Velde, Jeroen Kerrebijn Adenocarinoma of the ethmoidal sinuscomplex. Arch Otolaryngol Head Neck Surg 127 : 141-146 ; 2001•Pierre Lavertu, Jay K. Roberts, Dennis H. Kraus, Howard L. Levine, Benjamin G. Wood, Sharon V. Medendorp, Harvey M. Tucker Squamous cell carcinoma of the paranasal sinuses : the Cleveland Clinic experience 1977-1986 Laryngoscope 99 : November 1989•R. Christopher Miyamoto, Lyon L. Gleich, Paul W. Biddinger, Jack L. Gluckman Esthesioneuroblastoma and sinonasal undifferentiated carcinoma : impact of histological grading and clinical staging on survival and prognosis. Laryngoscope 110 : 1262-1265 ; 2000




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Nasal cavity and paranasal sinuses carcinoma